STEMI NSTEMI Programme An Initiative for Treating Heart

STEMI / NSTEMI Programme (An Initiative for Treating Heart Attacks by NHM-TAEI Tamil Nadu) DR. DAREZ AHAMED, IAS MISSION DIRECTOR – NHM TAMIL NADU

Scheme of presentation ▪ Problem statement ▪ Concept of STEMI/NSTEMI management- Hub and spoke model ▪ Tamilnadu experience in STEMI/NSTEMI ▪ Suggested Template for implementing in states

Heart Attacks ▪ STEMI – ST Elevation Myocardial Infarction ▪ NSTEMI – Non ST Elevation Myocardial Infarction

Problem Statement ▪ Ischemic heart disease is the leading cause of death in India. ▪ Roughly 10 million die per year in India (total deaths) ▪ STEMI incidence is 1. 1 per million i. e. 1. 34 million STEMI every year ▪ 3, 50000 to 400, 000 STEMI/NSTEMI deaths every year in India (10% mortality) i. e. around 1100 MI deaths per day ▪ Tamil Nadu- 20, 000 -25, 000 STEMI deaths every year i. e 55 STEMI deaths per day in the state.

Global Scenario- CVD ▪ CVDs are the number 1 cause of death globally: more people die annually from CVDs than from any other cause. ▪ An estimated 17. 9 million people died from CVDs in 2016, representing 31% of all global deaths. Of these deaths, 85% are due to heart attack and stroke. ▪ Over three quarters of CVD deaths take place in low- and middleincome countries. ▪ Out of the 17 million premature deaths (under the age of 70) due to NCDs in 2015, 82% are in low- and middle-income countries, and 37% are caused by CVDs. Source: WHO, 2018

Percent of Deaths in 2016 from disease categories in Tamil Nadu (Source : ICMR GBD report 2016) Non-communicable 69. 2% Communicable 17. 2% Injuries 13. 5% Cardiovascular diseases 36. 1 Diarrhea, lower respiratory, and other common infectious diseases 10. 6 Unintentional injuries Diabetes, urogenital, blood, and endocrine diseases 12. 2 HIV/AIDS and tuberculosis 3. 8 Self-harm and interpersonal violence 4. 3 Neoplasms Chronic respiratory diseases 7. 5 6. 5 1. 6 0. 5 Transport injuries 3. 2 Neurological disorders 2. 3 Neonatal disorders Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Digestive diseases 1. 7 Nutritional deficiencies 0. 2 Cirrhosis and other chronic liver diseases Other non-communicable diseases 1. 6 Maternal disorders 0. 1 Mental and substance use disorders Musculoskeletal disorders 0. 4 0. 8 0. 1 0. 4 6

Percent of DALYS in 2016 from disease categories in Tamil Nadu (Source : ICMR GBD report 2016) Non-communicable 65. 3% Communicable 20. 4% Injuries 14. 2% Cardiovascular diseases 19. 5 Diarrhoea, lower respiratory, and other common infectious diseases 7. 2 Unintentional injuries 5. 7 Diabetes, urogenital, blood, and endocrine diseases Other non-communicable diseases 9. 5 Nutritional deficiencies 4. 3 4. 8 7. 8 Neonatal disorders 4. 1 Self-harm and interpersonal violence Transport injuries Mental and substance use disorders 6. 8 HIV/AIDS and tuberculosis 3. 1 Musculoskeletal disorders 5. 6 0. 9 Chronic respiratory diseases 4. 9 Neglected tropical diseases and malaria Other communicable, maternal, neonatal, and nutritional diseases Neoplasms 4. 7 Maternal disorders 0. 2 Neurological disorders Cirrhosis and other chronic liver diseases Digestive diseases 4 1. 3 1. 2 0. 6 3. 7

Time is muscle / Muscle is life

STEMI Programme Components : HUB and Spoke Model : 4 major components ▪ HUB Hospital – having a Cath Lab ▪ A Hospital : has Cath Lab functioning 24 x 7 ▪ B Hospital : has Cath Lab functioning in Office Hours ▪ Spoke Hospital ▪ C Hospital : with ICU setting ▪ D Hospital : ECG facility ▪ 108 Ambulance Service – having facility to do an ECG and transmit to a HUB hospital for confirmation of STEMI ▪ Strategic purchasing ▪ CMCHIS ▪ PMJAY ▪ National health Protection Scheme / State Insurance scheme. Drugs and Consumables under NHM for supplementing medicines, stents , consumables etc for STEMI cases

Programme Implementation in Tamil Nadu ▪ Ambulance : STEMI Kit Equipments which Record ECG, Blood Pressure, SPO 2 (Saturation of Oxygen) in Ambulance and transmit electronically to Hub / Spoke Hospital ▪ Cath Labs established in 24 Hubs (17 NHM funded & 7 State funded) ▪ Training of Cardiologist, Physicians, staff nurses and Cath Lab technicians in STEMI management protocol ▪ Designation of STEMI Coordinator in each HUB hospital.

Programme Implementation ▪ Provision of STEMI kits and drugs to SPOKE hospitals. ▪ Implementation of STEMI/NSTEMI protocol in HUB with cath lab. ▪ Strengthening of CCUs in spoke hospitals to enable thrombolysis and stabilization. ▪ Linking Chief Ministers Comprehensive Insurance Scheme (CMCHIS) and PMJAY in Government hospitals by using existing Packages. ▪ Putting in place quality checks and creation of registry

Implementing Partners ▪ 108 Ambulance Services: Provides emergency Ambulance service ▪ Directorate of Medical Education: Runs Hub Hospitals ▪ Directorate of Medical and Rural Health Services: Runs Spoke Hospitals ▪ Chief Ministers Comprehensive Health Insurance Service (CMCHIS)/PMJAY : Provides insurance support for the program

Strengthening 108 Ambulance fleet: NHM Total Ambulances: 976 BLS Ambulances : 854 ACLS Ambulances: 56 Neonatal Ambulances: 66 No of ambulances 2013: 626 2018: 976

Cath lab network in Tamil Nadu • Phase 1 NHM ROP 2016 -2017 - 11 catheterisation labs • Phase 2 NHM ROP 2018 -2019 - 6 catheterisation labs Government c v c v cc vvc cv v Private 125 Cathlabs c v 2013 - 1: 25 2018 - 1: 5

STEMI Kit : Measure, Record, Transmit ▪ ECG ▪ Blood Pressure ▪ Oxygen Saturation

STEMI Cluster Class C Class D Class A/B Hospital Class C q Location of patient Class D q Location of closest STEMI hospital q Patient clinical condition o Fibrinolytic contraindications o cardiogenic shock Class C

Mode of Reperfusion ▪ Thrombolysis ▪ Primary Percutaneous Intervention ▪ Pharmaco-invasive Strategy (thrombolysis + invasive )

24 Cath Labs in Tamil Nadu : 24 Hubs ▪ 07 Cath Labs Established from State Budget ▪ 11 Cath Labs Established by ROP 2017 -18 ▪ 06 Cath Labs Being Established by ROP 2018 -19

Real Time App Based Report

How to Start STEMI Programme in Your State START WITH A SINGLE CLUSTER

A STEMI Cluster has: ▪ A Hub : Medical College/DHQ with Cath Lab ▪ For Angioplasty and Thrombolysis / Have STEMI Kits /console ▪ Few Spokes : District and Sub District Hospitals ▪ For Thrombolysis / Have STEMI Kits ▪ Ambulances with STEMI Kits ▪ Each of these have ▪ Non Recurrent Expenses ▪ Recurrent Expenses

STEMI Kits in Ambulances ▪ To Transmit in Real Time ▪ ▪ Patient ID and brief clinical history ECG Blood Pressure Oxygen Saturation ▪ Cost approximately 1 Lakh ▪ 1 per Ambulance ▪ Can be Included in PIP ▪ Console in HUB Hospitals for Cardiologist / Physician to take decisions

Thrombolysis ▪ Cost of Consumables : Streptokinase (1000 rs) vs r. TPA (1500020000 rs) covered under PMJAY ▪ Human Resources ▪ MBBS Doctor Trained in STEMI Protocol ▪ STEMI nurse trained in STEMI protocol ▪ 108 Amby technician trained in STEMI protocol ▪ Training can be Included in PIP

Angioplasty ▪ Non Recurrent Expense : ▪ Procurement of Cath Lab (Approximately 3 to 4 Crores) ▪ Can be Included in PIP ▪ Recurrent Expense : ▪ Consumables ▪ Human Resources ▪ Cardiologist ▪ Staff Nurses ▪ Technicians

Human Resources ▪ Qualification ▪ Training

Protocols ▪ Standard Protocols may be followed or Minor Modifications may be made

Funds ▪ NHM ▪ PMJAY ▪ State Funds

The infrastructure, Manpower, Equipment, Drugs and Consumable cost for one unit of HUB and Spoke(1 HUB, 6 Spokes –the lysed patient can be transported upto 100 kms only and travel time has to be limited to 2 to 3 hours only in an ambulance) has been worked out as under: 1. HUB Requirements: (24/7 Cath Lab) Components Details Infrastructure Cath lab Fully equipped CCU Manpower Cardiologist Scrub nurse Cath lab technicians Ward boys Non Recurring/ Recurring Non Recurring Source of Funding Quantity Per unit cost Total Already Funded by NHM 1 30, 00, 000 Recurring NHM/State Government fund 2 1, 50, 000 36, 000 Recurring NHM/State Government fund 6 1, 000 72, 000 Recurring To be Funded by NHM (outsourcing) 8 15, 000 14, 40, 000 To be Funded by NHM (outsourcing) 6 12, 000 8, 64, 000 To be Funded by NHM (outsourcing) 6 6, 000 4, 32, 000 Non Recurring 3, 50, 00, 000

Equipments STEMI kit Non Recurring Medications Stent & consumables ( Puncture needle, Arterial sheath, diagnostic catheter (for right & left), Guide wires Recurring (0. 032”), Guide cather’s, PTCA wire, Coronary stent, NC Balloon, “Y-Connector”, Inflation device, pressure tube To be Funded by NHM 1 1, 000 1200 cases** Drugs and diagnostics per annum under NHM/National requiring a procedure Health protection scheme/ State 3600 cases insurance require 30, 000 360, 000 angiogram - 1, 000 *Can also be ploughed back under National Health Protection Scheme/State Insurance Scheme and under drugs and consumables of NHM. ** It is estimated that at least 16 cases can be taken up in a day out of which 4 cases require Primary PCI / Pharmaco invasive PCI in a 24/7 facility Grand Total 876, 36, 000

• Spoke Requirements – Costing Components Details Non Recurring/ Recurring Quantity Per unit cost Total for 1 Spoke Well equipped Non Recurring ICU Already Funded by NHM 1 30, 00, 000 Manpower MO Nursing Team Paramedical Team STEMI kit 180, 000 Recurring State Government fund 2 60, 000 14, 40, 000 86, 40, 000 Recurring To be Funded by NHM (outsourcing) 4 15, 000 7, 20, 000 43, 20, 000 Recurring To be Funded by NHM (outsourcing) 4 12, 000 5, 76, 000 34, 56, 000 Equipments Total for 6 Spoke Infrastructure Medications Source of Funding Non Recurring To be Funded by NHM Recurring Drugs and diagnostics under NHM/National Health protection scheme/ State insurance Thrombolysis r. TPA 1 1, 000 1200 1, 000 20, 000 2, 40, 000 Grand Total 2, 98, 36, 000 *Can be ploughed back under National Health Protection scheme, State Health insurance scheme and Drugs and diagnostics under NHM 6, 000 14, 40, 000 17, 90, 16, 000

108 Ambulance Service Components Details Non Recurring/ Recurring Source of Funding Quantity Already Funded by NHM 30 15, 000 4, 50, 000 Already Funded by NHM / State 30 1, 50, 000 45, 000 To be Funded by NHM 30 1, 000 30, 000 Per unit cost Total Capex & Opex Non Recurring Ambulances Recurring Operation Cost Equipments Non Recurring STEMI kit Grand Total 5, 25, 000

4. Strategic purchase- -24*7 Cath Lab/hub - National Health protection scheme/state insurance scheme Components Details Source of Funding Quantity Per unit cost Total for 1 HUB & 6 Hospital Spokes 360, 000 Medications at HUB Hospital Medications at Spoke Hospital Funded under NHPS/ State PCI/ pharmaco- insurance and to be ploughed invasive Stent back into the system and & consumables hence a revenue for the Government Hospital 30, 000 1200 cases** per annum requiring a procedure 3600 cases require angiogram - Funded under NHPS/ State insurance and to be ploughed Thrombolysis back into the system and 1200 r. TPA hence a revenue for the Government Hospital 20, 000 Grand Total 360, 000 - 2, 40, 000 14, 40, 000 18, 00, 000

Cost estimate for a STEMI Cluster with 24/7 Cath lab (1 HUB + 6 Spokes + 30 Ambulances) Already Funded by NHM/National health protection scheme /State Health insurance scheme NHM/State To be Funded Government fund by NHM Sl. No. Component 1 HUB –MCH/ District Head Quarter Hospital 380. 00 360. 0 108. 00 28. 36 876. 36 2 Spoke – DH/Sub-district Hospital 180. 00 1440. 00 86. 40 83. 76 1790. 16 3 108 Ambulance Service 459. 00 36. 00 30. 00 525 Total 1019 1800 230. 4 142. 12 3191. 52 4 Strategic Purchase – National Health Protection scheme/ State Insurance scheme/ 1800. 00 5 Additional Budget Required to be provided by NHM ** It is estimated that at least 16 cases can be taken up in a day out of which 4 cases require Primary PCI / Pharmaco invasive PCI in a 24/7 facility Total 372. 52

Cost estimate for a STEMI Cluster with 24/7 Cath lab (1 HUB + 6 Spokes + 30 Ambulances) Recurring & non recurring Components Recurring Non-Recurring Total HUB – District Head Quarter Hospital 4, 95, 36, 000 3, 81, 000 8, 76, 36, 000 Spoke – Sub-district Hospital 16, 04, 16, 000 1, 86, 000 17, 90, 16, 000 45, 000 4, 80, 000 5, 25, 000 21, 44, 52, 000 10, 47, 000 31, 91, 52, 000 2144. 52 1047. 00 3191. 52 108 Ambulance Service Grand Total Amount in Lakhs

Take Home Message ▪ Non Communicable Diseases are Increasing ▪ Heart Attack is a Common Problem ▪ Heart Attack has High Mortality ▪It is Easy to Address this Challenge

▪ For copy of protocol please mail your request to rchpcni@tn. nic. in ▪ Contact no MD NHM TN (9443358888) THANK YOU